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Background Flexible endoscopic myotomy has been increasingly performed for Zenker’s diverticulum using various endoscopic techniques and devices. The main aims of this study were to assess practice patterns and compare outcomes of endoscopic myotomy for Zenker’s diverticulum. Methods Procedures performed at 12 tertiary endoscopy centers from 1/2012 to 12/2018 were reviewed. Patients (≥ 18 years) with Zenker’s diverticulum who had dysphagia and/or regurgitation and underwent endoscopic myotomy were included. Outcomes assessed included technical success, clinical success, and adverse events. Results 161 patients were included. Traditional endoscopic septotomy was performed most frequently (137/161, 85.1 %) followed by submucosal dissection of the septum and myotomy (24/161, 14.9 %). The hook knife (43/161, 26.7 %) and needle-knife (33/161, 20.5 %) were used most frequently. Overall, technical and clinical success rates were 98.1 % (158/161) and 78.1 % (96/123), respectively. Adverse events were noted in 13 patients (8.1 %). There was no significant difference in technical and clinical success between traditional septotomy and submucosal dissection groups (97.1 % vs. 95.8 %, P = 0.56 and 75.2 % vs. 90.9 %, P = 0.16, respectively). Clinical success was higher with the hook knife (96.7 %) compared with the needle-knife (76.6 %) and insulated tip knife (47.1 %). Outcomes were similar between centers performing > 20, 11 – 20, and ≤ 10 procedures. Conclusions Flexible endoscopic myotomy is an effective therapy for Zenker’s diverticulum, with a low rate of adverse events. There was no significant difference in outcomes between traditional septotomy and a submucosal dissection approach, or with centers with higher volume, though clinical success was higher with the hook knife. more...

Lynch syndrome (LS) is the most common hereditary colorectal cancer (CRC) syndrome, yet is grossly under-recognized. Multiple professional societies recommend screening all CRCs for LS by performing tumor testing. The veterans affairs system has not adopted universal tumor testing as a national performance metric and leaves screening for LS to clinical care at individual sites. Describe adherence to LS screening in the VA system. Dual-center, retrospective review of all CRCs diagnosed between 2010 and 2016. Rates of tumor testing, personal and family history of cancer were extracted from the medical record. Univariate and multivariate regression analysis was performed to determine predictors of tumor-based screening for LS. A total of 421 cancers were reviewed. 15.1% of all cancers underwent either MSI and/or IHC for LS screening over the study period. There was improvement in LS screening from 3% of all CRCs in 2010 to 45% of all CRCs in 2016. 34% and 70% of patients did not have documentation of CRC in first- and second-degree relatives, respectively. Of the 73 patients who met one of the Revised Bethesda Criteria or had a PREMM1,2,6 score of ≥ 5, 34% and 56% underwent tumor testing, respectively. Younger age, non-Caucasian race, meeting Bethesda or PREMM1,2,6 criteria and right-sided tumor location were predictors of undergoing tumor testing. CRC tumor screening for LS is grossly inadequate when left to routine clinical care. Our results lend support to implementation of reflexive universal tumor testing within the VA system. more...

Visible lesion (VL) detection is essential in patients with Barrett's Esophagus (BE). We sought to assess the rate of VL detection by academic and community endoscopists using high-definition white light endoscopy (HD-WLE) and narrow band imaging (NBI) during surveillance endoscopy.Fifty endoscopists were invited to participate in a prospective video survey study. Participants viewed 25 standardized clips of patients referred for endoscopic therapy. Participants noted identification of anatomic landmarks, VLs using HD-WLE and NBI, and reported practice level data. The gold standard of VL identification was established via consensus by 5 BE experts. Our primary outcome was the rate of VL identification using HD-WLE and NBI.44/50 participants completed the study (22 academic and 22 community). Compared to the gold standard, participants did not identify 28% (HD-WLE) and 31% (NBI) of VLs. Community endoscopists had more experience (5 years in practice: Community: 85% vs Academic: 54.5%, p=0.041;5 surveillance endoscopies/month: Community: 85% vs Academic: 31.8%, p=0.046). Across all participants, VL detection using NBI improved significantly with a minimum of 5 surveillance endoscopies/month (area under the curve: 0.72; 95% confidence interval: 0.56- 0.85; p=0.006).Despite improved endoscope resolution and availability of virtual chromoendoscopy, the overall rate of VL detection remains low. Identification of VLs using NBI may be volume dependent. Further education and training efforts focused on VL detection during Barrett's surveillance endoscopy are needed. more...

IntroductionIndia has the second highest number of people with diabetes, however few studies assessed true burden and ensured screening of pre-diabetics. This cross sectional survey (inception cohort) was conducted to estimate the burden and correlates of one of the common risk factors (hyperglycemia / diabetes) likely to impact the morbidity and mortality due to Non-communicable diseases.Research Design and MethodsA cross sectional survey was conducted in villages under Chittoor District, Andhra Pradesh, India. 15,888 individuals (62.1% females and 37.9% males) above 15 years of age participated in the study.Results960 (6.04%) had a history of diabetes while 592 (3.67%) had high random capillary blood glucose (RCBG) ≥200 mg/dL. HbA1c and fasting blood sugar was tested in a subset of those with high RCBG (n = 248) but with no self-reported diabetes and 212 (85.48%) had HbA1c levels > 6.5 and fasting blood sugar ≥126 mg/dL. Thus, 85.48% (n = 506) with high RCBG were likely to be diabetic. The likely magnitude of diabetes in the community was 9.23%. Another 2,331 (14.67%) were found to be at a higher risk of developing diabetes (RCBG 140 to 200 mg/dL). Receiver Operator Characteristic analysis revealed waist circumference as the most important anthropometric measurement predicting high RCBG. Comparison of diabetes and non-diabetics by multivariate logistic regression showed that male gender, age, weight, history of hypertension, family history of diabetes and waist circumference played a significant role in the prevalence of diabetes.ConclusionsThere is high prevalence of diabetes in the rural and semi-urban India. Waist Circumference was the best predictor of Diabetes. RCBG can be considered as a easy, cheap, reliable and important tool for community diagnosis and management of diabetes.Strengths and limitations of the studyA large planned cross-sectional survey to establish a cohort with community participationQuality assurance and control measures at all levels for high internl validityFollow up assurance for the entire communityThese results are from Cross Sectional survey data and thus provides only associationsGenerealizeability to similar populationsWhat is already known?Global burden of disease projected India to have a manifold increase in diabetes between 1995–2025.Diabetes threat is being under-prioritised with increasing pool of undiagnosed diabetes.What are the new findings?Total prevalence of Diabetes 9.77% and 14.67% were at risk of developing Diabetes85.5 % individuals with RCBG≥200mg/dL conform to diabetes as per ADA criteria.Waist Circumference was the best predictor of Diabetes.What do the new findings imply?RCBG can be a reliable, cheap and important tool for community diagnosis and management of diabetes.Cohort established, interventions being implememted with follow up. more...

While elevated blood pressure is a recognized risk factor for cardiovascular disease, the prevalence of hypertension still remains unclear for most populations. A door-to-door survey was conducted using modified WHO STEPS questionnaire in a group of villages under the Thavanampalle Mandal of Chittoor District in the state of Andhra Pradesh of South India. Data were collated and analyzed for 16,636 individuals (62.3% females and 37.7% males) above 15 years of age. Overall, prevalence of hypertension (as per JNC-7 classification) was found to be 27.0% (95% CI, 26.3, 27.7) in the surveyed community with 56.7% of the total hypertensives being diagnosed for the first time during the survey. An additional 39.1% had their blood pressure readings in the prehypertensive range. Among the known Hypertensives on treatment only 46.2% had a blood pressure recording within acceptable limits, with 31.2% in the prehypertensive range and only 15.0% in the normal range. Systolic blood pressure (SBP) of the surveyed population showed a continuous linear increase with age, but diastolic blood pressure (DBP) peaked and started reducing in early fifth decade in males. Male gender, increasing age, higher body mass index (BMI), increased waist-hip ratio, increased body weight, family history of hypertension, death of spouse, and diabetes were found to be positively correlated with hypertension. Risk factors of alcohol intake, use of ground nut/palm oil, and family history of diabetes lost their independent predictive ability for hypertension on multivariate logistic regression analysis. The level of physical activity was also not found to be a significant predictor of hypertension in the study population. more...

Peroral endoscopic myotomy (POEM) is a minimally invasive natural orifice endoscopic surgical procedure initially developed for treatment of achalasia. Recent studies have shown excellent clinical and safety outcomes in all types of achalasia, and even spastic esophageal disorders. POEM is a complex and technically challenging procedure with risk of potentially serious adverse events. Hence, appropriate training is essential for POEM, even for advanced endoscopists with extensive experience in interventional endoscopy. A few studies have suggested preclinical training using ex vivo and live animal models, with successful transition to human cases but standardized training pathways have not been defined yet. As with other new techniques, there is a learning curve for training in POEM and the number of procedures required to master the technique varies depending on prior endoscopic experience and skill. Procedure time has been shown to improve with case volume, though competence may not be defined only by procedure time and number of procedures performed. In this report, we evaluate training avenues for POEM and suggest competency assessment metrics. Further studies are required to define objective measures of performance and quality metrics for this new endoscopic surgical procedure. more...

The disease obesity continues to be a major health issue in the United States and abroad due to its prevalence and associated comorbidities. Treatment has consisted of lifestyle intervention, pharmacotherapy, and surgery; however, this treatment paradigm has not resulted in a decrease in the prevalence of obesity in the United States. The Food and Drug Administration (FDA) has recently approved four gastric endoscopic bariatric therapies (EBTs) for the primary treatment of obesity. These include three intragastric balloons (IGBs) (the ReShape Dual Balloon, the Orbera Balloon System, and the Obalon Balloon System) and the ASpireAssist System. These therapies provide additional options for treatment of obesity. They provide more weight loss than lifestyle intervention and pharmacotherapy, but less weight loss than bariatric surgery. However, they are also less invasive and carry less risk than bariatric surgery, which may make EBTs a more acceptable treatment to many patients. more...

Per-Oral Endoscopic Myotomy (POEM) is a novel flexible endoscopic procedure initially developed for the treatment of achalasia but has recently gained widespread use for other gastrointestinal motility disorders. Essentially, POEM involves submucosal tunneling in the esophagus to perform myotomy under a protective mucosal flap. The endoscopic techniques and indications for POEM are evolving. This chapter will focus on current endoscopic techniques for POEM and review various approaches for the procedure with emphasis on technical strategies, devices used, and equipment needed. more...

We sought to quantify socioeconomic disparities in patients with severe aortic stenosis (AS) undergoing transcatheter aortic valve replacement (TAVR) at an urban, tertiary referral center. This retrospective case-control study identified 67 patients with severe AS (aortic valve [AV] area ≤1 cm2 or AV area index ≤0.60 cm2/m2 or AV velocity ≥40 mmHg) who underwent TAVR from November 5, 2013 to June 10, 2014. Study subjects were matched to controls with severe AS without TAVR in a 4:1 age-frequency match. Demographic data were collected using electronic medical records. Area-based median household income was obtained by geocoding patients’ addresses and linking with census data. Charlson comorbidity index for all subjects was calculated. Income disparity was significant in that with every $10,000 increase in income, the odds of receiving TAVR increased by 10% (p = 0.05). Non-blacks were significantly more likely to receive TAVR than blacks (odds ratio [OR] 2.812, confidence interval [CI] 1.007–7.853; p = 0.048). No differences in comorbidities were found between the two groups. Post hoc analysis to identify etiologies of the found disparities examined differences of AV area and AV area index, indication for two-dimensional echocardiography (echo), symptoms prior to echo, and action after echo within the control group. Black race significantly impacted the TAVR status despite the same AV area (OR 0.33, CI 0.09–0.97, p = 0.043). After echo, blacks were more likely to decline AVR, be lost to follow-up, and not be referred to cardiology (OR 4.41, CI 1.43–13.64; p = 0.010). Socioeconomic and racial disparities were associated with patients with severe AS receiving TAVR at a major referral center. This study emphasizes the importance of improving access to standard of care for these subgroups of cardiac patients. more...

Clostridium difficile infection (CDI) is a significant healthcare burden, with increased morbidity and mortality. Traditional treatment regimens using antibiotics for recurrent CDI are significantly less successful compared with 80-90% with fecal microbiota transplantation (FMT). There is a paucity of data on failure rates and mortality after FMT in CDI. This study aims to identify the rates of failure, relapse, and mortality associated with FMT as well as the risk factors for FMT failure.A large retrospective cohort study was carried out including all patients who underwent FMT from December 2012 through May 2014. Patient factors (demographics, comorbidities, immune-suppression, transplant history, antibiotics used, hospitalization, and surgeries), disease factors (number of episodes of CDI, treatments, and severity), and transplant factors (route and number of FMT) were examined. Failure of treatment was defined as no resolution of diarrhea in patients who had been treated with one or more fecal microbiota transplantation within 90 days of FMT.A total of 201 patients (age 66.6±18.3 years, 62.2% women) were included. The overall failure rate was 12.4%. Patients with failed fecal transplant had increased number of FMTs compared with those who responded (mean 1.92±0.997 vs. 1.29±0.615; P=0.004). No colectomies or death related to CDI were found in our patient population. Significant predictors of failure were female sex (P=0.016), previous hospitalization (P=0.006), and surgery before FMT (P=0.005). The overall mortality rate was 9.0% and failure of FMT was associated with an increased risk of death (odds ratio=5.833, confidence interval 2.01-16.925; P0.05).FMT is a suitable alterative to antibiotic use for recurrent CDIs, with a high success rate. The results indicate that hospital-acquired CDI may be a predictor of failure of FMT. more...

Background and Aims Per-oral pancreatoscopy (POP) permits direct evaluation of the pancreatic duct for the visualization and sampling of neoplastic lesions and treatment of pancreatic duct stones by using intraductal lithotripsy techniques. Pancreatic laser endotherapy of mucosa has been described in animal models for tumor ablation, but human experience is lacking. We describe 3 unique and challenging clinical situations that benefited from pancreatic laser dissection and ablation. Case description Case 1 was a 75-year-old woman with presumed divisum-associated chronic pancreatitis who had recurrent acute pancreatitis despite minor papilla sphincterotomy and therapeutic stent placement. POP showed a side-branch intraductal papillary mucinous neoplasm within the neck of the pancreas. POP-guided holmium laser ablation of neoplastic tissue was performed, followed by pancreatic stent placement every 6 months, with no further hospitalizations at 20 months of follow-up. Case 2 was a 69-year-old woman with divisum-associated chronic calcific pancreatitis and recalcitrant mid-body stenosis. Previous attempts at balloon dilation and stent placement failed to resolve the stenosis. POP-guided holmium laser dissection of the stenosis was pursued, with immediate radiographic resolution. Case 3 was a 65-year-old woman with chronic calcific pancreatitis and a large stone burden who underwent POP-guided electrohydraulic lithotripsy and partial stone extraction followed by stent placement. Unfortunately, the stent fractured during the subsequent removal attempt because the fragment was impacted in the pancreatic body. POP-guided laser dissection and lithotripsy were used to debulk dense fibrous tissue and stones surrounding the stent fragment, respectively, followed by removal. Conclusions Pancreatoscopy-guided laser endotherapy is a novel and potentially useful technique to manage difficult benign and neoplastic pancreatic disorders. more...

Advanced endoscopy is vastly expanding in its practical implications and complexity. Over the years, the role of advanced endoscopic procedures has expanded from a primarily diagnostic to complex diagnostic and therapeutic procedures with many conditions that were managed surgically in the past being managed effectively with endoscopic approaches. With the increasing complexity of these procedures, training in advanced endoscopy has gained paramount importance. Training in advanced endoscopy requires acquisition of many skills – technical, cognitive, and integrative, those beyond standard endoscopic skills acquired during a 3-year training program. Expertise in basic endoscopy is a prerequisite for learning advanced endoscopy. Given the overall complexity of these procedures, adequate and appropriate training in advanced endoscopy is critical. These procedures are highly operator dependent and associated with higher rates of adverse events including life-threatening bleeding, perforation, and pancreatitis (Andriulli A, Loperfido S, Napolitano G, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2007;102(8):1781–8). Given the changing healthcare landscape, reimbursements will soon be linked to performance and quality of care provided. Hence, in this era of value-based care, adequate training in advanced endoscopy is critical to ensure that quality metrics in endoscopy are being met. more...

Per-oral endoscopic myotomy (POEM) is an innovative natural orifice flexible endoscopic procedure that involves myotomy of distal esophagus via a sub-mucosal tunneling approach. The procedure was first performed by Inoue et al. (1) and has evolved significantly since then. The focus of this update i more...

Background and Aims Through-the-needle microforceps are a recent addition to the EUS armamentarium for evaluation of pancreatic cystic lesions (PCLs). The main aim of this study was to assess the technical feasibility, diagnostic yield, and safety of EUS-guided microforceps biopsy for PCLs. Methods Our electronic endoscopy database was queried to identify patients who underwent EUS-guided FNA (EUS-FNA) of PCLs and microforceps biopsies during the same procedure. A biopsy was done on the wall of the cyst with the microforceps through the 19-gauge needle, and cyst fluid was collected for cytology and carcinoembryonic antigen (CEA) levels. Adverse events were recorded per published American Society for Gastrointestinal Endoscopy criteria. Results Twenty-seven patients underwent EUS-FNA and microforceps biopsy of PCLs from February 2016 to July 2017. Fourteen cysts were located in the pancreatic head and/or uncinate, and 13 were located in the body and/or tail region. Microforceps biopsies were technically successful in all cases and provided a pathology diagnosis in 24 of 27 cases (yield 88.9%). Microforceps biopsies diagnosed mucinous cyst in 9 patients (33.3%), serous cystadenoma in 4 (14.8%), neuroendocrine tumor in 1 (3.7%), and benign and/or inflammatory cyst in 10 (37.1%). In 7 patients (26%), microforceps biopsy results drastically changed the diagnosis, providing diagnoses otherwise not suggested by cytology or cyst fluid CEA levels. However, cytology provided a diagnosis of mucinous cyst in 4 cases (14.8%) not detected by microforceps biopsies. No adverse events were noted. Conclusion Microforceps biopsies were associated with high technical success, and an excellent safety profile and may be a useful adjunctive tool, complementing existing EUS-FNA sampling protocols for PCLs. more...

Acute cellular rejection (ACR) is a significant cause of morbidity and graft failure in liver transplant recipients (LTR). Diastolic dysfunction (DD) is frequently present in patients with cirrhosis undergoing liver transplantation. However, it is unclear if DD leads to ACR.Data was collected retrospectively for consecutive LTR between January 2000 and December 2010. Demographic data and mortality related data was obtained from social security index. Primary outcome was biopsy proven ACR. Graft failure and all-cause mortality were also evaluated. DD was evaluated as a predictor of these outcomes. Other echocardiographic indices were also assessed as predictors of ACR by using Cox proportional hazard modeling adjusted for covariates.A total of 970 LTR (mean age 53.2 ± 10 years, women 34.6 % and white 64.5 %) were followed for 5.3 ± 3.4 years. Patients with DD (n = 145, 14.9 %) were significantly more likely to develop ACRs (HR 10.56; 95 % CI 6.78-16.45, p value = 0.0001) as well as graft failure (HR 2.09; 95 % CI 1.22-3.59, p value = 0.007) and all-cause mortality (HR 1.52; 95 % CI 1.08-2.13, p = 0.01). There was an increase in the risk of these outcomes with worsening of DD, when adjusted for various risk factors such as donor and recipient age, gender, race, Framingham risk score, pre-transplant MELD, transplant etiology and cold ischemia time.Pre-transplant DD is significantly associated with increased risk of allograft rejection, graft failure and mortality. This signifies the importance of cardiac evaluation during the pre-transplant period. more...

Background BK virus (BKV)-associated nephropathy (BKVAN) is a major cause of renal dysfunction and graft loss in renal transplant recipients. Monitoring plasma BK viral load (BKVL) is the recommended screening tool to predict BKVAN. American Society of Transplantation (AST) guidelines define a BKVL of ≥4 log10/mL (10,000 copies) as presumptive BKVAN and recommend reduction in immunosuppression. We evaluated the clinical sensitivity of the quantitative BKV DNA assay in predicting risk for BKVAN using the AST-recommended BKVL cutoff. Methods In a retrospective, single-center study, all patients who underwent renal transplant at Henry Ford Hospital from January 2008 to August 2011 were analyzed (n = 490). Plasma BKVL Assay A (commercial large T antigen-based polymerase chain reaction [PCR]) was done in all patients. Renal biopsy was done if there was a rise in serum creatinine ≥0.5 mg from baseline. BKVAN was confirmed by biopsy. As a subset to this study, from the same cohort, data for a set of 20 consecutive Assays A and B (in-house VP1-based PCR assay) from 15 patients over a period of 3 months were collected. Differences in physicians' clinical decision-making (CDM) were analyzed between the 2 assays using chi-square test. Results A total of 413 patients met the inclusion criteria, of which 222 patients had BK viremia. Among the 248 patients who had a renal biopsy done, 31 (12.5%) were found to have BKVAN. Eleven of the 31 (35%) patients had BKVL consistently more...

We investigated a unique microzone of the cerebellum located in folium-p (fp) of rabbit flocculus. In fp, Purkinje cells were potently excited by stimulation of the hypothalamus or mesencephalic periaqueductal gray, which induced defense reactions. Using multiple neuroscience techniques, we determined that this excitation was mediated via beaded axons of orexinergic hypothalamic neurons passing collaterals through the mesencephalic periaqueductal gray. Axonal tracing studies using DiI and biotinylated dextran amine evidenced the projection of fp Purkinje cells to the ventrolateral corner of the ipsilateral parabrachial nucleus (PBN). Because, in defense reactions, arterial blood flow has been known to redistribute from visceral organs to active muscles, we hypothesized that, via PBN, fp adaptively controls arterial blood flow redistribution under orexin-mediated neuromodulation that could occur in defense behavior. This hypothesis was supported by our finding that climbing fiber signals to fp Purkinje cells were elicited by stimulation of the aortic nerve, a high arterial blood pressure, or a high potassium concentration in muscles, all implying errors in the control of arterial blood flow. We further examined the arterial blood flow redistribution elicited by electric foot shock stimuli in awake, behaving rabbits. We found that systemic administration of an orexin antagonist attenuated the redistribution and that lesioning of fp caused an imbalance in the redistribution between active muscles and visceral organs. Lesioning of fp also diminished foot shock-induced increases in the mean arterial blood pressure. These results collectively support the hypothesis that the fp microcomplex adaptively controls defense reactions under orexin-mediated neuromodulation. more...

Objectives of this study were (1) to evaluate preoperative predictors of systolic and diastolic heart failure in patients undergoing liver transplantation (LT) and (2) to describe the prognostic implications of systolic and diastolic heart failure in these patients. The onset of heart failure after orthotopic LT remains poorly understood. Data were obtained for all LT recipients between January 2000 and December 2010. The primary outcome was post-LT heart failure: systolic (ejection fraction ≤ 50%), diastolic, or mixed heart failure. Patients underwent echocardiographic evaluation before and after LT. Pretransplant variables were evaluated as predictors of heart failure with Cox proportional hazards model. 970 LT recipients were followed for 5.3 ± 3.4 years. Ninety-eight patients (10.1%) developed heart failure in the posttransplant period. There were 67 systolic (6.9%), 24 diastolic (2.5%), and 7 mixed systolic/diastolic (0.7%) heart failures. Etiology was ischemic in 18 (18.4%), tachycardia-induced in 8 (8.2%), valvular in 7 (7.1%), alcohol-related in 4 (4.1%), hypertensive heart disease in 3 (3.1%), and nonischemic in majority of patients (59.2%). Pretransplant grade 3 diastolic dysfunction, diabetes, hypertension, mean arterial pressure ≤ 65 mm Hg, mean pulmonary artery pressure ≥ 30 mm Hg, mean pulmonary capillary wedge pressure ≥ 15 mm Hg, hemodialysis, brain natriuretic peptide level and QT interval > 450 ms were found to be predictive for the development of new-onset systolic heart failure. However beta-blocker use before LT and tacrolimus after LT were associated with reduced development of new-onset systolic heart failure. In conclusion, pretransplant risk factors, hemodynamic variables, and echocardiographic variables are important predictors of post-LT heart failure. In patients undergoing LT, postoperative onset of systolic or diastolic heart failure was found to be an independent predictor of mortality. Liver Transpl 19:701–710, 2013. © 2013 AASLD. more...

Hyponatremia has significant prognostic implications in patients with heart, failure. However, little data are available regarding its significance in patients presenting with myocardial infarction. In addition, it is not known if correction of hyponatremia impacts outcomes in these patients. The aim of this study was to evaluate the prognostic value of hyponatremia in patients with myocardial infarction and the effect of its correction on all-cause mortality. Patients with the discharge diagnosis of myocardial infarction at our institution between 2000 and 2010 with serum sodium levels measured within 24 h of admission were included in this retrospective analysis. Multivariate analysis was used to determine the predictors of all-cause mortality. Cox proportional hazard model was applied to determine the adjusted survival. A total of 11,562 patients (67.15 ± 14.6 years, males 56.3 %) were included in the analysis. There were a total of 1,535 (13.3 %) deaths within mean follow-up duration of 5.5 ± 3.3 years. There were 425 (27.9 %) deaths in patients with corrected hyponatremia and 155 (55.3 %) deaths in persistent hyponatremia patients. Multivariate analysis indicated that corrected hyponatremia and persistent hyponatremia were independent predictors of all cause mortality (p more...

Data regarding the outcomes of restarting anticoagulation in patients who develop gastrointestinal bleeding (GIB) while anticoagulated are sparse. We hypothesized that restarting anticoagulation in these patients is associated with better outcomes. This is a retrospective cohort study that enrolled subjects who developed GIB while on anticoagulation from 2005 to 2010. Atrial fibrillation was defined by history and electrocardiography on presentation. GIB was defined as a decrease in hemoglobin by 2 g, visible bleeding, or positive endoscopic evaluation. Time-to-event adjusted analyses were performed to find an association of restarting warfarin and recurrent GIB, arterial thromboembolism, and mortality. Stratified analysis by duration of interruption of warfarin was also performed. Overall, 1,329 patients (mean age 76 years, women 45%) developed major GIB. Warfarin was restarted in 653 cases (49.1%). Restarting warfarin was associated with decreased thromboembolism (hazard ratio [HR] 1.18, 95% confidence interval [CI] 0.75 to 1.84, p = 0.47) [corrected] and reduced mortality (HR 0.67, 95% CI 0.56 to 0.81, p0.0001) but not recurrent GIB (HR 1.18, 95% CI 0.94 to 1.10, p = 0.47). When the outcomes were stratified by duration of warfarin interruption, restarting warfarin after 7 days was not associated with increased risk of GIB but was associated with decreased risk of mortality and thromboembolism compared with resuming after 30 days of interruption. Decision to restart warfarin after an episode of major GIB is associated with improved survival and decreased thromboembolism without increased risk of GIB after 7 days of interruption. more...

Background: With better health care, hematopoietic stem cell transplantation has become possible for older patients. These patients have higher prevalence of diastolic dysfunction. However, it is not known if diastolic dysfunction has an impact on prognosis of these patients. Methods: Retrospective data was obtained for adults (>18 years) that underwent hematopoietic stem cell transplantation over a period of 1991 - 2012 (22 years). Demographic, echocardiogrpahic and mortality data were obtained. Cox proportional hazard model was used to analyze diastolic dysfunction as a predictor of mortality, graft versus host disease (GVHD), systolic heart failure (ejection fraction ≤50%) and sepsis. Diastolic dysfunction was defined according to American Society of Echocardiography guidelines. Results: Out of 770 patients (mean age 48.9±13.4, women 47.7%) had 91 (11.8%) patients with pre - transplant diastolic dysfunction. Patients with diastolic dysfunction were more likely to be older, hypertensive, ≥2 comorbidities and suffer from solid organ malignancy (p Conclusion: Pre - transplant diastolic dysfunction in this group of patients was associated with worse prognosis after transplantation. These findings might help guide therapies and early treatment/management of these patients, so that these complications might be prevented. more...

Background: Racial disparities are well known in patients treated for atrial fibrillation (AF). Racial minorities are less likely to be treated and diagnosed with atrial fibrillation. However, it is not known if gastrointestinal bleeding which is common complication in anticoagulated atrial fibrillation patients leads to any racial disparities. Methods: Retrospective data was obtained from claims of warfarin prescriptions made to a large insurance company of South Eastern Michigan. Patients with gastrointestinal bleeding were confirmed by detailed chart review. GIB was defined as a drop of 2 gram of hemoglobin or need for blood transfusion in the setting of one of the symptoms of GIB confirmed by hospital staff. A propensity matched multivariable logistic regression analysis was performed to assess the likelihood of being resumed on warfarin. Recurrent GIB, stroke/TIA and mortality rates were also compared between Caucasians and African Americans.The analysis was adjusted for propensity score, blood transfusions, length of stay, CHADS2 and HAS - BLED scores. Results: Out of 118,342 initially obtained patients on warfarin, there were 1143 (mean age 75.8 ± 14.7, women 46%) patients that developed gastrointestinal bleeding while on anticoagulation for AF. There were 776 (58.38%) Caucasians and 367 (27.6%) African American (AA) patients. Out of these, 339 (43.7%) Caucasians and 189 (55.7%) AA patients were resumed on warfarin (p = 0.001). Warfarin was resumed later in Caucasians than AA (68 vs. 64 days, p = 0.03). AA were more likely to not resume warfarin due to personal preference or negative experience with warfarin and Caucasians were more likely to not resume warfarin due to doctor’s suspicion of higher risk of bleeding (p Conclusion: In conclusion, the racial disparity in resuming warfarin after an episode of major GIB in anticoagulated patients for atrial fibrillation was more for Caucasians than African American. This may be explained by uncertainty of outcomes that frequently leads to overtreatment of minority patients. Cultural beliefs for not resuming warfarin might have also played a role. more...